Senior Consultant – Clinical Utilization Management SME

Location: Remote

Company

hirify.global delivers digital services and technology solutions for federal agencies supporting the health and safety of veterans, service members, and civilians.

What you will do

• Provide clinical subject-matter expertise in utilization management, care management, medical necessity, and clinical review.
• Assess referral, authorization, utilization-management, and care-coordination workflows to identify barriers to timely care.
• Evaluate utilization trends, clinical and operational drivers of variation, and opportunities to improve access, quality, appropriateness, cost, and patient outcomes.
• Develop and refine clinical workflows, protocols, decision support, and standard operating procedures.
• Conduct root-cause analyses involving denials, medical documentation, access, utilization, care coordination, and patient-care impacts.
• Prepare clinical recommendations, executive analyses, risk analyses, performance frameworks, and implementation or change-management materials while collaborating with VA stakeholders and healthcare professionals.

Requirements

• 7+ years of experience in healthcare clinical operations, utilization management, care management, case management, clinical review, or a related field.
• Experience with medical-necessity review, prior authorization, concurrent or retrospective review, appeals, or care management.
• Active, unrestricted Registered Nurse (RN) license and a bachelor's degree; BSN preferred.
• Experience with Medicare Advantage, Medicaid, commercial payer, or government payer operations and healthcare documentation.
• Experience with InterQual, MCG/Care Guidelines, or comparable clinical decision-support tools.
• Strong written and verbal communication skills, with the ability to translate clinical findings into operational and executive recommendations.

Nice to have

• 3+ years of direct utilization-management or clinical review experience.
• Utilization-management accreditation or quality experience.
• Population health, behavioral health, post-acute, specialty, emergency, or high-cost/high-risk population experience.
• VA/VHA experience.
• CCM, ACM, CPHQ, or similar certification.

Culture & Benefits

• Top-tier benefits supporting physical, mental, and financial health and wellness.
• Growth-minded and entrepreneurial work environment.
• Opportunities to learn new skills, take on challenges, and advance professionally.
• Inclusive culture focused on personal and professional development.
• Veterans, transitioning service members, and military spouses are strongly encouraged to apply.